Part two of a two part series on exercise and pelvic pain.
Last week we posted a blog about whether there are any exercises that patients can do that would help with their pelvic pain healing. In this week’s blog we’re going to look at the second common question our pelvic pain patients ask regarding exercise:
“As far as my general fitness routine, are there any exercises that I shouldn’t do that may exacerbate my symptoms? And are there exercises that you specifically recommend for me based on my findings?”
Exercising for fitness often poses a problem for patients who are in the middle of the healing process causing their symptoms to flare. Often this occurs after patients have taken a break from their fitness routine because of their pelvic pain and/or fear of making themselves worse. After they return to exercise they oftentimes will start to become symptomatic again as a result.
Understandably this is very frustrating and people think they may never be able to exercise again.
It’s important for people to get daily exercise, so we work hard with patients to figure out the balance between staying fit and healthy and not exacerbating their symptoms. Therefore, exercise routines may need temporary modifications at first, with the goal being progression towards the patient’s desired activities.
So after years of conversations with my patients and a knowledge of exercise anatomy and physiology, we compiled a list of exercises that are reasonable starting places for people beginning to work out again as well as a list of activities that are often more provocative for pelvic pain patients.
The advice below is by no means and end-all be-all of “do’s and ‘don’ts”. I created it because I want people to know that they can exercise, and certain choices may be better than others when learning to manage pelvic pain.
A-List of Exercises for Pelvic Pain Patients
Slower, isometric, double-limb, lower impact exercises:
People that have been through any pain experience may have altered neuromuscular recruitment patterns. What this means is that they may use muscles other than the ones intended for the movement in question, which can result in injury and symptoms. Therefore, in general, slower, isometric, double-limb, lower impact exercises are a good place to start. With these types of exercises, the patient has a higher chance of performing the necessary motions with proper muscle recruitment as compared to faster moving, higher impact, and single-leg stance activities. Below is a list of examples of these types of exercises.
Shallow squats are better because the deeper the squat, the greater the chance that hypertonic (too tight) muscles will change the motion and that the external rotators and hamstring muscles instead of the gluteal muscles will get involved, which are the muscles you want to be working in this type of exercise.
Progression: shallow squats on a foam pad
This movement creates an unstable surface and co-contraction of muscles, and is a safe and effective way to strengthen the gluteus muscles, thighs, and hips.
Balancing on the Bosu ball or foam roller
If using the Bosu Ball, first use the flat side down, then progress to flat side up for 30 seconds to two minutes.
Abdominal Exercises that are appropriate for pelvic pain patients
Abdominal muscles are often associated with pelvic pain; therefore, some abdominal exercise can exacerbate symptoms. Below are the abdominal exercises that we recommend for patients with pelvic pain. For a variety of reasons, these exercises do not negatively impact the pelvic floor.
Plank: these are great because they are a good way to recruitment trunk muscles.
Standing Triceps Extensions: these create a way to recruit the core without over-activating the rectus abdominus muscles.
Supine leg-lifts on a physio ball: again, these create a way to recruit the core without over-activating the rectus abdominus muscles.
Walking backwards on a treadmill at 5% incline, 2.0 miles per hour.
This will help to strengthen the lower extremities while also providing an aerobic activity, but it will do so in a way that doesn’t engage those muscles that are a problem like the pelvic floor and the rectus abdominus muscles.
The StepMill cardiovascular machine that most gyms have.
This machine is great because at slower speeds (less than level five), people can get great gluteal muscle recruitment while also getting cardiovascular benefits.
Exercises that are more provocative and may flare symptoms:
Activities that involve impact, such as single leg or double leg jumping
Squatting in single leg stance
- Hamstring and quadriceps machines
General fitness principles recommend free weights over gym machines. Many of my female patients report that these machines simply feel uncomfortable and exacerbate their symptoms.
Deep squats and lunges
When folks who have pelvic pain do squats or lunges, their hamstrings oftentimes fire instead of their gluteal muscles, which can be detrimental to a tight pelvic floor. Also, pelvic pain patients often have hip rotators that are too tight to be able to do the exercise properly.
Biking or spinning
Most people with pelvic pain have problems and pain in the muscles that are compressed on a bike seat, i.e. nearly the entire pelvic floor. So the pressure will aggravate the pelvic floor. In fact, some of our patients’ pain started as a result of biking in the first place. I’m not saying that if you’re a passionate cyclist and develop pelvic pain that you’ll never be able to ride again, but for those who are in treatment these exercises are not the best choices.
Sitting abduction/adduction machine (inner/outer thigh)
The sitting adduction and abduction machine is not a functional exercise, meaning that we do not use these muscles in our daily lives in the positions required on these machines, so unless you’re a competitive weightlifter, there really is no functional reason to do these exercises. On top of that, these machines can actually cause pelvic pain and, therefore, should be avoided.
Unless you are a professional body builder, most people do not need to strengthen their calf muscles. The general population tends to have tight calf muscles, which can change how a person walks and the muscles that they use daily. These muscles should be stretched versus strengthened, and daily.
Situps or crunches
Sit-ups directly involve the rectus abdominus muscles, one of the abdominal muscles, which have a high correlation with pelvic pain or a high tone pelvic floor as well as urinary urgency and frequency. In addition, this muscle is not a trunk stabilizer and does not need to be individually strengthened for musculoskeletal health.
Deep squats with heavy weights
Deep squats with heavy resistance are not a good choice due to a higher risk of injury and incorrect muscle recruitment. This position also causes a lengthening of the pudendal nerve and a tightening of the pelvic floor muscles. This combination can cause pudendal neuralgia.
May or May not be Appropriate for Pelvic Pain Patients
Patients who have trigger points in their hips or if their gluteal muscles aren’t strong enough, running is going to bother their pelvic floor symptoms, but if they are clear in those areas they can usually slowly start to get back into running.
Swimming is a great form of exercise. Certain strokes may be problematic for patients with trigger points. For example, the breaststroke activates the obturator internus muscle, patients with trigger points here should choose a different stroke, such as freestyle. Conversely, patients with psoas or hip flexor trigger points may get aggravated by the freestyle motion, but feel comfortable using the breaststroke.
But walking in water can be a fantastic cardiovascular exercise because it gets your heart rate up but because we’re practically weightless in water, muscles and joints are free of pressure.
Pilates and yoga
These exercises have a range of motions that can be therapeutic for pelvic pain, good for general fitness, and occasionally problematic. Therefore, pilates or yoga programs really need to be individualized per patient. To read more about yoga and pelvic pain, check out our blog on the topic here.
When it comes to exercise and pelvic pain it’s important for me as a PT to help my patients find that happy medium between continuing to exercise and stay fit and not exacerbating their pelvic pain symptoms. Not only because it adds to their quality of life and overall health, but because any exercise, and especially cardiovascular exercise will encourage blood flow and release endorphins, which is beneficial for patients in pain.
Please share your experiences with us about what has and has not worked for you and any questions that you may have!
All my best,